Right Lower Quadrant Pain due to Eosinophilc Eosophagitis

An 8-year-old boy is seen by his pediatrician for follow-up of abdominal pain. He had already visited the ER last week for RLQ abdominal pain and acute appendicitis had been ruled out. He complained of abdominal pain radiating to RLQ, nausea, vomiting, lack of appetite and weight loss for 6 months.

Past medical history (PMH)

Allergic rhinitis and conjunctivitis for 3 years, skin prick testing positive for house dust mite (2 years ago)

Fluticasone (Flovent) PO was started with rapid resolution of symptoms within 2-3 weeks. The patient's appetite improved greatly and he gained 10 pounds during a 6-month period.

Pulmicort (budesonide) Respules, 0.5/2 mL PO bid may work better than fluticasone spray since the patients actually drinks the viscous liquid rather than using a spray.

What is the correct way to use fluticasone PO in eosinophilic esophagitis?

Fluticasone is used twice daily -- after breakfast and after dinner. After the puff, the patient should attempt to swallow. The same is repeated with the second puff. The mouth is rinsed with water and the water is swallowed. No food should be eaten for 2 hours.

What are the typical symptoms of eosinophilic esophagitis in different age groups?

Infants present with vomiting.Children present with abdominal pain and vomiting.Older children present with the feeling that the "food is stuck."

What is the prognosis for resolution of eosinophilic esophagitis?

Uncertain.

85% of children with atopic dermatitis eventually become asymptomatic.85% of children with asthma eventually become asymptomatic.50% of children with allergic rhinitis eventually become asymptomatic.

There is a paucity of data to predict outcomes in eosinophilic esophagitis.

Final diagnosis

Eosinophilic esophagitis.

How to make budesonide viscous solution?

Pulmicort (budesonide) Respules, 0.5/2 mL PO bid may work better than fluticasone spray since the patients actually drinks the liquid rather than using a spray.

Mix Pulmicort Respules® (or generic budesonide) with sucralose. Each milligram of budesonide is mixed with 10 sucralose packets (Splenda®). In one pediatric study, if children's height was under 5 feet, they received 1 mg; if they were over five feet, they received 2 mg.

Two inhaled corticosteroids have been used to treat eosinophilic esophagitis - fluticasone and budesonide.

The usual starting dose of budesonide in an adult is a 1 mg ampule mixed with a slurry of artificial sweetener (usually sucralose) using 10 packets, dependent upon taste, and swallowed b.i.d. In a child, 0.5 mg can be used in the same way, mixed with 5 packets.

Fluticasone is typically started at a dose of 440 mcg b.i.d. This can be lowered to 220 mcg b.i.d. subsequently.

@DrSilge: Dr. Aceves says that they use 0.5 mg budesonide respules in 5 packets, not the 1 mg. If need higher dose, use 10 packets. She states that want the volume for surface area, moreso than the higher concentration of medication.